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Getting the most out of your medicines - a Pharmacists guide

How to maximise the benefits of your medicines – Medication Adherence

Today in Ireland we have an elderly population (65+yrs) of 637,567 which equates to 13.4% of the population. Some 65% of this population suffer from two or more chronic disease (e.g. Diabetes and High Blood Pressure) and they are required to take multiple medications to help control these problems.  As the complexity of health problems increase, this puts an increasing burden of managing treatment on the patient and their families. Evidence shows that the more complex a treatment regimen becomes, the higher the risk that the patient is not following or adhering to the treatment guidelines. This means that many patients living with multiple conditions do not get to reap the benefit of their prescribed medicines which we know will work if taken correctly. It can also lead to unnecessary suffering and wasted resources; however, patients are often reluctant to tell their doctor or pharmacist that they do not take their medicines or that they struggle to take their medicines correctly. Does this sound like you or someone you know?  Help is available at your local pharmacy, including Whelehans Pharmacies at Pearse St and Clonmore Mullingar through speaking with your pharmacist. Your pharmacist is a medicines expert and can provide a medicines review (explaining what the medicines do and how best to take them) and possible introduction of weekly/monthly blister packs. Importantly there is no additional charge to the patient for this service at Whelehans Pharmacies, Mullingar.

Financial and health costs of not taking your medicines properly

Non-adherence to prescribed medication is costing EU governments approximately €125 billion annually and more importantly contributes to the premature deaths of 200,000 Europeans per year. In the Irish population, more than €319 million is spent each year on medicines for the one in five of the population aged over 50 with polypharmacy (use of many medicines at one time). When long-term medication is prescribed for patients with chronic diseases, it is estimated that approximately 50% of individuals fail to adhere to the prescribed regimen.

 “Drugs don't work in patients who don't take them” C. Everett Koop, M.D.

If you do not take your medication, it is not going to work – it is that simple! But adherence is not simple. The reasons behind medication adherence are complex, and can sometimes go beyond a lack of information, forgetfulness, or even access to medication itself. Understanding the complexity of non-adherence factors is key to addressing the issue. “Non-adherence” simply means not taking your medicines as your doctor intended you to take them.

Non-adherence categorized as two types: intentional and unintentional.

Unintentional non-adherence relates to barriers beyond a person’s control which prevent them from following a prescribed treatment. These include obstacles such as financial barriers, lack of information or understanding about their condition or prescribed treatment, forgetfulness, and ability.

Intentionally not taking your medicines

Intentional non-adherence relates to the persons beliefs, perceptions and motivations, where a person is reluctant to adhere due to attitudes, concerns, opinions or fears.

One useful way to establish what might be driving non-adherence is known as the ‘Perceptions and Practicalities approach’. Perceptions refers to how people’s beliefs about medicines might explain their medication taking behaviour. For example, patients may have concerns about potential harmful side-effects or believe that prolonged use of medicines might be toxic. Some patients may not see medicines as being necessary. This is particularly the case in conditions that are asymptomatic (no obvious symptom to patient) such as hypertension (high blood pressure) or hyperlipidaemia (high cholesterol). The medications used to treat these conditions are also typically experienced as neutral which might initially seem positive. However, when patients feel no different whether they take or fail to take their medications this can pose a problem for long-term adherence.

Un-Intentionally not taking your medicines

Practicalities refer to all those factors that are not about the patients’ motivation to take their medication. This can include memory problems, costs, access to medications and lack of skill in taking medication appropriately. 

Questions to ask your doctor or pharmacist

Here are some key questions that you as the patient can discuss with your pharmacist or doctor to help initiate, frame and guide a conversation about your medicine taking:

  1. Opener: E.g. I have a lot of medications to manage. E.g. I am taking my medications by doing the following ...?
  2. Elicit more information/guidance from your pharmacist /doctor-: Are there any medications that you, the patient would be less likely to take? Why is that? Are you worried? Do you think they are doing you any good?
  3. Is there anything that you could do differently that you think would help with taking the medications?

Help to ensure you take your medication as prescribed

Here are some general strategies that might be helpful:

  1. Some patients can get their medications provided in reminder packaging by the pharmacist. You might want to ask about that – Monitored Dosage Systems (MDS) or “Blister Packs” (I will discuss blister packs in greater detail later)
  2. Some patients find it helpful to link taking their medication to a routine they do every day. For example, brushing their teeth or having a cup of tea in the morning or evening after they have eaten. Would that work for you?
  3. Is there anyone at home that can give you a reminder to take your medications or make sure that you have them available? Put a reminder into your phone or get someone to do so for you.
  4. Let’s see what happens to your blood pressure/cholesterol/other relevant sign or symptom over the next few weeks if you can take all doses of your medication as and when prescribed.

Medication Adherence

Capability, Opportunity and Motivation all influence how you take your prescribed medication.

Capability -Do you have the physical and psychological capacity to take the medication as prescribed? E.g. – Do you have arthritis which make opening tablet containers difficult? (Did you know that you can ask for tablet vials without the child resistant closures to improve ease of opening?); Do you have any memory difficulties? (Ask about getting your medication in a weekly or monthly blister pack) –

Opportunity -Do you have physical opportunity to take the medication as prescribed? Is it easy to source, collect and pay for the medication? (Many pharmacies provide a prescription home delivery service to patients including Whelehans – just ring and ask if you think it will benefit your situation- Importantly at Whelehans there is no additional charge to the patient for this service.

Motivation-Do you want to (i.e., have the motivation) take the medication as prescribed? Have you noticed any bad side effects? Many medicines cause side effects especially when you are elderly and take several medicines, this can make it very difficult for a patient to take them every day as prescribed.

Unintentional reasons may be due to forgetfulness, confusion or a lack of integrating medication-taking into daily routine. If this is you, then you might benefit from an organizational based approach to improving adherence like blister packs form your local pharmacy.

Monitored dosage systems (MDS) – “Blister Packs”
Monitored dosage systems (MDS) – “Blister Packs” can be created in your local pharmacy. There are multiple types and different options for patients, depending on individual concerns. An MDS is any medication storage and organisational device designed to simplify patients’ medication usage and commonly comes in the form of a box or blister pack divided into the days of the week and times of day. Tray-style blister packs are suitable for home use. There are other pouch/bubble-type systems (Bio-Dose) available which are for people with more active lifestyles, as individual timeslots containing medications can be taken out of the tray.

Determining if you can benefit from your medicines in a “blister pack”

Some of the criteria used by your pharmacist to determine if the patient would benefit from a blister pack includes the following:

  • Is the patient on a complex medication system?
  • Is the patient confused about medication instructions?
  • Does the patient regularly forget to take their mediation?
  • Is there evidence of medication wastage/medication returns to the pharmacy?
  • Does the patient visit the pharmacy irregularly to collect their medication?
  • Has the patients’ carer/nurse/doctor requested assistance or raised medicine adherence concerns?
  • Does the patient have learning difficulties, eyesight problems or dementia?

Whelehans Pharmacy Mullingar provide this “Blister Pack” service to all patients who fulfil some of the criteria outlined above and importantly this is done at NO ADDITIONAL COST to the patient.

It is important to understand that not all medicines can be included into the “Blister Packs” perhaps due to their prescribing directions (i.e. take only when needed), their stability or storage requirements. The blister packs require advance planning, so it is always important to notify your pharmacist at least 48 hours in advance of when the next pack is due.

Your pharmacist can help simplify your complex medication regime

“Blister Packs” provide patients and their families support in managing their healthcare requirements especially as they age, and their needs become more complex. Elderly patients living alone can retain independent living with supervision as required, confident that their medication needs are been looked after correctly.

Another option is to reduce the number of tablets to be taken by patients with multimorbidity (many health conditions), a move toward combination products available can be utilised (e.g. 3 active ingredients in one tablet). However, the increased cost of these formulations must be kept in mind. This can be discussed in further detail with your doctor or pharmacist.

Additionally, the use of prolonged release formulations (where clinically suitable) would further reduce the frequency of taking a tablet. So, a once daily prolonged release tablet is better than a twice daily tablet, in terms of adherence. This can be discussed in further detail with your doctor or pharmacist.

Pharmacists are in a great position for medication review due to monthly interactions with the patient/carer or families and clear insight into what medications are actually collected on a regular basis (versus what is prescribed). These consultations are also an opportunity for patient education and feedback on effectiveness and side effects of therapy and may require feedback to and communication with doctors (to optimize medicine regime); however clear consent will be obtained by your pharmacist to avoid breakdown of patient trust.

Thanks to Breda Heneghan MPSI, Pharmacist at Whelehans Pharmacy, 38 Pearse St, Mullingar who researched and wrote this article.

Should you wish to get your medicines or the medicines of a loved one organised into simple Weekly/ Monthly Blister packs, contact our pharmacist at either of our pharmacies. Dial 04493 34591 for Whelehans Pearse St or 04493 10266 for Whelehans Clonmore Mullingar. This is a free service at Whelehans.